HOW TO DIAGNOSE AND MANAGE ACUTE PANCREATITIS: GUIDELINES BY International Association of Pancreatology, and American Pancreatic Association.

HOW TO DIAGNOSE AND MANAGE ACUTE PANCREATITIS: GUIDELINES BY International Association of Pancreatology, and American Pancreatic Association.

Summary of recommendations

A. Diagnosis of acute pancreatitis and etiology

1. The definition of acute pancreatitis is based on the fulfillment of ‘2 out of 3’ of the following criteria: clinical (upper abdominal pain), laboratory (serum amylase or lipase

>3x upper limit of normal) and/or imaging (CT, MRI, ultrasonography) criteria.(GRADE 1B, strong agreement)

2. On admission, the etiology of acute pancreatitis should be determined using detailed personal (i.e. previous acute pancreatitis, known gallstone disease, alcohol intake,

medication and drug intake, known hyperlipidemia, trauma, recent invasive procedures such as ERCP) and family history of pancreatic disease, physical examination,

laboratory serum tests (i.e. liver enzymes, calcium, triglycerides), and imaging (i.e. right upper quadrant ultrasonography).(GRADE 1B, strong agreement)

3. In patients considered to have idiopathic acute pancreatitis, after negative routine work-up for biliary etiology, endoscopic ultrasonography (EUS) is recommended as

the first step to assess for occult microlithiasis, neoplasms and chronic pancreatitis. If EUS is negative, (secretin-stimulated) MRCP is advised as a second step to identify

rare morphologic abnormalities. CT of the abdomen should be performed. If etiology remains unidentified, especially after a second attack of idiopathic pancreatitis,

genetic counseling (not necessarily genetic testing) should be considered.(GRADE 2C, weak agreement)

B. Prognostication/prediction of severity

4. Systemic inflammatory response syndrome (SIRS) is advised to predict severe acute pancreatitis at admission and persistent SIRS at 48 hours.(GRADE 2B, weak

agreement)

5. During admission, a 3-dimension approach is advised to predict outcome of acute pancreatitis combining host risk factors (e.g. age, co-morbidity, body mass index),

clinical risk stratification (e.g. persistent SIRS) and monitoring response to initial therapy (e.g. persistent SIRS, blood urea nitrogen, creatinine).(GRADE 2B, strong

agreement)

C. Imaging

6. The indication for initial CT assessment in acute pancreatitis can be: 1) diagnostic uncertainty, 2) confirmation of severity based on clinical predictors of severe acute

pancreatitis, or 3) failure to respond to conservative treatment or in the setting of clinical deterioration. Optimal timing for initial CT assessment is at least 72e96 hours

after onset of symptoms.(GRADE 1C, strong agreement)

7. Follow up CT or MR in acute pancreatitis is indicated when there is a lack of clinical improvement, clinical deterioration, or especially when invasive intervention is

considered.(GRADE 1C, strong agreement)

8. It is recommended to perform multidetector CT with thin collimation and slice thickness (i.e. 5mm or less), 100e150 ml of non-ionic intra-venous contrast material at a

rate of 3mL/s, during the pancreatic and/or portal venous phase (i.e. 50e70 seconds delay). During follow up only a portal venous phase (monophasic) is generally

sufficient. For MR, the recommendation is to perform axial FS-T2 and FS-T1 scanning before and after intravenous gadolinium contrast administration.(GRADE 1C,

strong agreement)

D. Fluid therapy

9. Ringer’s lactate is recommended for initial fluid resuscitation in acute pancreatitis.(GRADE 1B, strong agreement)

10a. Goal directed intravenous fluid therapy with 5e10 ml/kg/h should be used initially until resuscitation goals (see Q10b) are reached.(GRADE 1B, weak agreement)

10b. The preferred approach to assessing the response to fluid resuscitation should be based on one or more of the following: 1) non-invasive clinical targets of heart rate <

120/min, mean arterial pressure between 65-85 mmHg (8.7e11.3 kPa), and urinary output > 0.5e1ml/kg/h, 2) invasive clinical targets of stroke volume variation, and

intrathoracic blood volume determination, and 3) biochemical targets of hematocrit 35-44%.(GRADE 2B, weak agreement)

E. Intensive care management

11. Patients diagnosed with acute pancreatitis and one or more of the parameters identified at admission as defined by the guidelines of the Society of Critical Care

Medicine (SCCM). Furthermore, patients with severe acute pancreatitis as defined by the revised Atlanta Classification (i.e. persistent organ failure) should be treated in

an intensive care setting.(GRADE 1C, strong agreement)

12. Management in, or referral to, a specialist center is necessary for patients with severe acute pancreatitis and for those who may need interventional radiologic,

endoscopic, or surgical intervention.(GRADE 1C, strong agreement)

13. A specialist center in the management of acute pancreatitis is defined as a high volume center with up-to-date intensive care facilities including options for organ

replacement therapy, and with daily (i.e. 7 days per week) access to interventional radiology, interventional endoscopy with EUS and ERCP assistance as well as surgical

expertise in managing necrotizing pancreatitis. Patients should be enrolled in prospective audits for quality control issues and into clinical trials whenever

possible.(GRADE 2C, weak agreement)

14. Early fluid resuscitation within the first 24 hours of admission for acute pancreatitis is associated with decreased rates of persistent SIRS and organ failure.(GRADE 1C,

strong agreement)

15. Abdominal compartment syndrome (ACS) is defined as a sustained intra-abdominal pressure > 20 mmHg that is associated with new onset organ failure.(GRADE 2B,

strong agreement)

16. Medical treatment of ACS should target 1) hollow-viscera volume, 2) intra/extra vascular fluid and 3) abdominal wall expansion. Invasive treatment should only be

used after multidisciplinary discussion in patients with a sustained intra-abdominal pressure >25mmHg with new onset organ failure refractory to medical therapy and

nasogastric/ rectal decompression. Invasive treatment options include percutaneous catheter drainage of ascites, midline laparostomy, bilateral subcostal laparostomy,

or subcutaneous linea alba fasciotomy. In case of surgical decompression, the retroperitoneal cavity and the omental bursa should be left intact to reduce the risk of

infecting peripancreatic and pancreatic necrosis.(GRADE 2C, strong agreement)

F. Preventing infectious complications

17. Intravenous antibiotic prophylaxis is not recommended for the prevention of infectious complications in acute pancreatitis.(GRADE 1B, strong agreement)

18. Selective gut decontamination has shown some benefits in preventing infectious complications in acute pancreatitis, but further studies are needed.(GRADE 2B, weak

agreement)

19. Probiotic prophylaxis is not recommended for the prevention of infectious complications in acute pancreatitis.(GRADE 1B, strong agreement)

G. Nutritional support

20. Oral feeding in predicted mild pancreatitis can be restarted once abdominal pain is decreasing and inflammatory markers are improving.(GRADE 2B, strong agreement)

21. Enteral tube feeding should be the primary therapy in patients with predicted severe acute pancreatitis who require nutritional support.(GRADE 1B, strong agreement)

22. Either elemental or polymeric enteral nutrition formulations can be used in acute pancreatitis.(GRADE 2B, strong agreement)

23. Enteral nutrition in acute pancreatitis can be administered via either the nasojejunal or nasogastric route.(GRADE 2A, strong agreement)

24. Parenteral nutrition can be administered in acute pancreatitis as second-line therapy if nasojejunal tube feeding is not tolerated and nutritional support is

required.(GRADE 2C, strong agreement)

H. Biliary tract management

25. ERCP is not indicated in predicted mild biliary pancreatitis without cholangitis.(GRADE 1A, strong agreement). ERCP is probably not indicated in predicted severe

biliary pancreatitis without cholangitis (GRADE 1B, strong agreement). ERCP is probably indicated in biliary pancreatitis with common bile duct obstruction (GRADE 1C,

strong agreement) ERCP is indicated in patients with biliary pancreatitis and cholangitis (GRADE 1B, strong agreement)

26. Urgent ERCP (<24 hrs) is required in patients with acute cholangitis. Currently, there is no evidence regarding the optimal timing of ERCP in patients with biliary

pancreatitis without cholangitis.(GRADE 2C, strong agreement)

27. MRCP and EUS may prevent a proportion of ERCPs that would otherwise be performed for suspected common bile duct stones in patients with biliary pancreatitis who

do not have cholangitis, without influencing the clinical course. EUS is superior to MRCP in excluding the presence of small (<5mm) gallstones. MRCP is less invasive,

less operator-dependent and probably more widely available than EUS. Therefore, in clinical practice there is no clear superiority for either MRCP or EUS.(GRADE 2C,

strong agreement)

I. Indications for intervention in necrotizing pancreatitis

28. Common indications for intervention (either radiological, endoscopical or surgical) in necrotizing pancreatitis are: 1) Clinical suspicion of, or documented infected

necrotizing pancreatitis with clinical deterioration, preferably when the necrosis has become walled-off, 2) In the absence of documented infected necrotizing

pancreatitis, ongoing organ failure for several weeks after the onset of acute pancreatitis, preferably when the necrosis has become walled-off.(GRADE 1C, strong

agreement)

29. Routine percutaneous fine needle aspiration of peripancreatic collections to detect bacteria is not indicated, because clinical signs (i.e. persistent fever, increasing

inflammatory markers) and imaging signs (i.e. gas in peripancreatic collections) are accurate predictors of infected necrosis in the majority of patients. Although the

diagnosis of infection can be confirmed by fine needle aspiration (FNA), there is a risk of false-negative results.(GRADE 1C, strong agreement)

30. Indications for intervention (either radiological, endoscopical or surgical) in sterile necrotizing pancreatitis are: 1) Ongoing gastric outlet, intestinal, or biliary

obstruction due to mass effect of walled-off necrosis (i.e. arbitrarily >4-8 weeks after onset of acute pancreatitis), 2) Persistent symptoms (e.g. pain, ‘persistent

unwellness’) in patients with walled-off necrosis without signs of infection (i.e. arbitrarily >8 weeks after onset of acute pancreatitis), 3) Disconnected duct syndrome

(i.e. full transection of the pancreatic duct in the presence of pancreatic necrosis) with persisting symptomatic (e.g. pain, obstruction) collection(s) with necrosis without

signs of infections (i.e. arbitrarily >8 weeks after onset of acute pancreatitis).(GRADE 2C, strong agreement)

J. Timing of intervention in necrotizing pancreatitis

31. For patients with proven or suspected infected necrotizing pancreatitis, invasive intervention (i.e. percutaneous catheter drainage, endoscopic transluminal drainage/

necrosectomy, minimally invasive or open necrosectomy) should be delayed where possible until at least 4 weeks after initial presentation to allow the collection to

become ‘walled-off’.(GRADE 1C, strong agreement)

32. The best available evidence suggests that surgical necrosectomy should ideally be delayed until collections have become walled-off, typically 4 weeks after the onset of

pancreatitis, in all patients with complications of necrosis. No subgroups have been identified that might benefit from earlier or delayed intervention.(GRADE 1C, strong

agreement)

K. Intervention strategies in necrotizing pancreatitis

33. The optimal interventional strategy for patients with suspected or confirmed infected necrotizing pancreatitis is initial image-guided percutaneous (retroperitoneal)

catheter drainage or endoscopic transluminal drainage, followed, if necessary, by endoscopic or surgical necrosectomy.(GRADE 1A, strong agreement)

34. Percutaneous catheter or endoscopic transmural drainage should be the first step in the treatment of patients with suspected or confirmed (walled-off) infected

necrotizing pancreatitis.(GRADE 1A, strong agreement)

35. There are insufficient data to define subgroups of patients with suspected or confirmed infected necrotizing pancreatitis who would benefit from a different treatment

strategy.(GRADE 2C, strong agreement)

L. Timing of cholecystectomy (or endoscopic sphincterotomy)

36. Cholecystectomy during index admission for mild biliary pancreatitis appears safe and is recommended. Interval cholecystectomy after mild biliary pancreatitis is

associated with a substantial risk of readmission for recurrent biliary events, especially recurrent biliary pancreatitis.(GRADE 1C, strong agreement)

37. Cholecystectomy should be delayed in patients with peripancreatic collections until the collections either resolve or if they persist beyond 6 weeks, at which time

cholecystectomy can be performed safely.(GRADE 2C, strong agreement)

38. In patients with biliary pancreatitis who have undergone sphincterotomy and are fit for surgery, cholecystectomy is advised, because ERCP and sphincterotomy

prevent recurrence of biliary pancreatitis but not gallstone related gallbladder disease, i.e. biliary colic and cholecystitis.(GRADE 2B, strong agreement)